Organization of Medication Provision for Privileged Categories of Citizens and Ways of Its Improvement at the Primary Ambulatory-Polyclinic Level

The dissertation is devoted to the problems of organizing medication provision for privileged categories of citizens at the primary ambulatory-polyclinic level (municipal polyclinic). The study examines various systems of benefit-based medication provision in foreign countries and regions of Russia, analyzes changes in legislation related to medication provision for citizens, and evaluates economic expenditures on benefit-based medication provision across the polyclinic as a whole and by individual beneficiary categories.

The study investigates the patient cohort attached for benefit-based medication provision, calculates the average cost of treatment in groups of "regional" and "federal" beneficiaries, and conducts a comparative analysis of the cost of medication treatment recommended by standards versus the actual cost of treatment for patients with the most prevalent diseases (bronchial asthma, diseases among disabled persons and participants of the Great Patriotic War). Special attention is given to the influence of the number of concomitant diseases on treatment costs, as well as to the analysis of changes in the organization of benefit-based medication provision before and after the introduction of Federal Law No. 122-FZ of 22.08.2004. The results are supplemented by a medico-sociological study of patients using free medication provision.

Relevance of the Study.

Social protection of the population has always been one of the principal criteria for evaluating the socio-political and economic state of society. The wealthier a country is, the more developed its system of institutions guaranteeing and simultaneously controlling the provision of social benefits to citizens is. It is also evident that there exists a certain "lower" minimum threshold of social welfare, the absence of which threatens social tension and, in the extreme case, social upheavals. The prevention of social upheavals requires state social guarantees: guarantees of medical care, including medication provision, as well as education and pension support.

The long-standing practice in domestic medicine of total subsidization of medical services, when hospital care was entirely free and the cost of medications during outpatient treatment was purely nominal and did not reflect the actual cost of drugs, is no longer effective. This was possible under the economic system that existed at the time, which was able to accumulate significant funds at the expense of minimizing the real wages of the population. The transition to a market economy has substantially reduced the possibilities of state subsidization.

Despite this, medical care in treatment-and-prophylactic institutions and hospitals has remained free for patients, although the mechanism of financing treatment-and-prophylactic institutions has changed significantly. The introduction of compulsory medical insurance throughout all regions of Russia, including Moscow, has made it possible to move away from the residual principle of financing and has promoted the emergence of an independent source of revenue specifically intended for the development and maintenance of the city's medical institutions.

A different situation has developed in the medication provision market. Rising prices for pharmaceutical preparations have rendered them essentially inaccessible to the underprivileged majority of the population.

The number of pensioners in the country in 2002 reached 39 million. The average pension amounted to 1,378.5 rubles, while the subsistence minimum for pensioners was 1,432 rubles. In 1990, with a pension of 132 rubles, the minimum food basket cost 23.4 rubles and housing rent 13 rubles, constituting 27.6% of the pension; in 2003, the same minimum food basket cost 1,181 rubles and housing rent 800 rubles, which together exceed the pension amount (Komarov Yu.M. 2003).

According to the Russian Federal State Statistics Service, the income of the top 10% of the most affluent citizens is 13 times higher than that of the bottom 10% of the least affluent, whereas in Western countries this ratio does not exceed 4-5 times (Semyonov V.Yu., Grishin V.V. 1997).

Furthermore, the number of persons entitled to benefit-based medication provision is continuously increasing. However, the realization of these benefits is not backed by the necessary financing (Lisitsyn Yu.P., Starodubov V.I., Grishin V.V., Semyonov V.Yu., Savelyeva E.N. 1994, Tukhbatullina R.G., Safiulin R.S. 1999, Gerasimenko N.F. 2004).

In addition to the main decreed groups of the population (disabled persons of the first group, non-working disabled persons of the second group, disabled persons and participants of the Great Patriotic War, children up to three years of age, etc.), a sharp expansion of the category of "underprivileged population" has occurred in modern Russia through the addition of new groups. These include the unemployed, parents and wives of deceased military personnel, and other categories of economically active population who are also entitled to benefit-based medication provision.

According to the Russian Ministry of Health, in 1996, benefit-based medication provision (via free prescriptions and 50% discounts on prescription costs) was used by approximately 45 million people (30% of the population of the Russian Federation), and by 2003 this figure had reached 50 million people.

It is important to emphasize that 17 million people (11.6% of the total population of the Russian Federation) are entitled to the complete free purchase of medications (Sinyavsky V.M., Zhuravlev V.A., Frolova V.A. 2004).

In absolute terms, the budgetary appropriations for the purchase of medications show a constant tendency toward growth, and the proportion of benefit-based and free prescriptions among the total number of prescriptions issued has increased sharply. In this connection, one of the most important tasks of healthcare organization at the present stage is the optimization of medication provision, which is achieved through various forms and methods (Vyazhov A.I., 2001; Goncharenko V.L., 1998, 1999; Lindenbraten A.L., 1996; Starodubov V.I., 2000; Shevchenko Yu.L., 2001).

Particular relevance is acquired by the rational use of available funds not only overall for the Russian Federation and individual regions, but directly at the level of the primary ambulatory-polyclinic level.

The works of a number of authors (Apazov A.D., 1991-2000; Borisenko T.V., 1996; Bykova A.V., 1997; Glebotskaya G.T., 1999; Goncharenko V.L., 1999; Moshkova L.V., 1998; Vasserman B.Ya. 2001) have been devoted to these questions.

These studies were directed toward the study and overcoming of difficulties in the benefit-based and free dispensing of medications and contributed to the development of technologies for improving the quality of pharmaceutical care.

However, the questions of calculating the average cost of treatment for individual groups of "beneficiaries" have remained practically unstudied; a comparative analysis of the cost of drugs recommended by "standards" and the actual cost of treatment for beneficiary groups with the most prevalent diseases has not been conducted; the cost of treatment for individual beneficiary groups depending on the number of concomitant diseases has not been analyzed.

The relevance of the work lies in the fact that under conditions of insufficient financing of benefit-based medication provision for citizens, the problem of rational use of allocated funds is further exacerbated, that is, the search for ways to improve the organization of medication provision for privileged categories of citizens at the primary ambulatory-polyclinic level — the municipal polyclinic. Goal of the work:

On the basis of an analysis of the organization of medication provision for privileged categories of citizens, to identify problems and determine ways of improving them at the primary ambulatory-polyclinic level — the municipal polyclinic.

To achieve the stated goal, it was necessary to solve the following tasks:

1. To analyze the population cohort attached for benefit-based medication provision and determine the proportion of various "privileged" categories of citizens.

2. To calculate the average cost of treatment in groups of "regional" and "federal" beneficiaries and to identify among them the population groups that are most "cost-intensive" for further study.

3. To conduct a comparative analysis of the cost of drugs recommended by "standards" and the actual cost of treatment for beneficiary groups with the most prevalent diseases, and to determine the reasons for their differences.

4. To conduct an analysis of the cost of treatment for individual beneficiary groups depending on the number of concomitant diseases.

5. To identify problems in the organization of benefit-based medication provision in the municipal polyclinic based on the results of a sociological survey of patients.

6. To provide a comparative characterization of the organization of benefit-based medication provision before and after the introduction of Federal Law No. 122-FZ of 22.08.2004.

7. To develop ways of improving the organization of medication provision for privileged categories of citizens at the primary ambulatory-polyclinic level — the municipal polyclinic.

Scientific novelty. The novelty of the present study lies in the fact that for the first time:

• an investigation of the organization of medication provision for privileged categories of citizens at the primary ambulatory-polyclinic level — the municipal polyclinic — has been conducted;

• the proportion of various categories of beneficiaries in the structure of expenditures on benefit-based medication provision at the municipal polyclinic level has been determined;

• the average monthly cost of drug treatment in groups of "federal" and "regional" beneficiaries has been calculated;

• a comparative analysis of the cost of medication treatment recommended by standards and the actual cost of treatment for patients with the most prevalent diseases has been conducted;

• an analysis of the cost of medication treatment for individual beneficiary groups depending on the number of concomitant diseases has been conducted;

• the fluctuation of expenditures on benefit-based medication provision depending on the month of the year has been studied;

• benefit-based medication provision before and after the introduction of the new "law on benefits" has been analyzed;

• ways of improving the organization of medication provision for privileged categories of citizens at the primary ambulatory-polyclinic level — the municipal polyclinic — have been developed.

Practical significance. On the basis of the obtained results, a scientifically substantiated approach to medication provision for citizens under conditions of a deficit of funds allocated for free and benefit-based medication provision for citizens is proposed.

Verification of research results. The materials of the dissertation research were reported at a joint meeting of the teams of the Department of Public Health and Healthcare Organization with a Course of Economics, the Department of Sociology and Economics of Healthcare of the Moscow Medical Academy named after I.M. Sechenov. The main provisions put forward for defense:

1. A socio-hygienic characterization of "privileged" categories of citizens at the primary ambulatory-polyclinic level — the municipal polyclinic.

2. The redistribution of volumes of financial funds allocated to the polyclinic among individual beneficiary groups depending on the severity of the disease and the number of concomitant diseases contributes to the fulfillment of the financial plan.

3. A comparative analysis of benefit-based medication provision before and after the introduction of Federal Law No. 122-FZ of 22.08.2004 has made it possible to identify unresolved problems and to determine ways of improving the organization of medication provision for privileged categories of citizens at the municipal polyclinic level.